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GP specialists help to enhance provision of local clinical services

Setting up a network of GPs with special interests can mean more flexible services for patients and greater job satisfaction for GPs, as Maureen Bower explains

In 1999 Bradford South & West PCT decided to set up a network of GP specialists to provide a wider range of services for patients. The PCT intended to build on the existing experience of GPs and nurses in the group, to:

Reduce waiting times and speed up the diagnostic process for those needing more complex services.

Aid GPs’ professional development and enable them to specialise in areas of interest.

Release consultants’ time to deal with more appropriate cases.

A wide range of skills was identified among GPs working as clinical assistants in the local hospital and nurses who had undergone additional training. Consequently, the services developed cover a wide scope. Box 1 (below) lists the specialties and numbers of staff who work in them.

Drugs and alcohol
3 GPwSIs (working from the premises of the charity Ripple)

Mental health counselling
1 GPwSI

Minor surgery
12 GPwSIs working in practices across the PCT

Ophthalmic surgery
1 GPwSI and nurse support

Sigmoidoscopy
1 GPwSI, 2 nurses with extended skills

All the GPs with a special interest (GPwSIs) have trained alongside local consultants and, where available, they have attained further qualifications in their specialties, for example the University of Wales College of Medicine Diploma in Practical Dermatology.

How does the system work?

The referring GP sends the referral letter to the team at the diagnostic treatment centre, where the details are immediately recorded on computer. This is an important part of the process and serves as a safety net for any inappropriate referrals that need to be passed to the acute trust, ensuring that they do not get lost between primary and secondary care.

Inappropriate referrals include cases of suspected cancer or conditions that are excluded from the referral protocol. In these cases the referring GP is alerted and the referral immediately sent to the most appropriate clinic. This ensures that GPs always know what stage the patient’s referral has reached.

From this point on, as the patient is referred through the triage process, all tests requested, results, appointments, diagnoses and other notes are updated on the patient record. Up-to-date information is therefore always available to members of the team.

Although there are similarities in the way each service deals with patients, the process is usually tailored to the individual specialty. Cystoscopy patients, for example, are given information by the dedicated nursing team and booked centrally onto the next GPwSI list at one of the three locations where the service is provided.

Ear, nose and throat referral letters are read by two GPwSIs and coded with their requirements. Urgent referrals are slotted into the next available clinic; patients who need to be seen by a consultant are booked into a joint GPwSI and consultant clinic, and those requiring audiology tests are seen on the day by the audiologist who works alongside the GPwSI for the whole session. This saves the patient having to make a second journey.

The process is designed to ensure that the patient journey is as smooth as possible and that the administration system is simple, reducing any delays in treatment.

Urology triage

The urology triage system run from the diagnostic treatment centre is one of the most streamlined services. The system is now being taken up by the other two Bradford PCTs, making the patient pathway consistent across the whole district:

Referrals from GPs are received and recorded at the central triage office.

A team of nurses supported by the urology GPwSI perform the triage working to strict protocols agreed with the acute trust consultants.

All the appropriate tests, including cystoscopy are organised at this point. The patients are sent information and details of the tests being arranged for them. They are also given a contact number to phone if they wish to discuss any concerns.

The patient is kept informed and supported throughout his or her journey by the nursing team at the centre.

The patient will be booked into a clinic to see a consultant only when all the information needed to make a decision on treatment is available.

The consultation takes place at the diagnostic treatment centre, which the consultants visit weekly or monthly, depending on the specialty. All the consultants can be easily contacted if the GPwSIs need support.

If a bladder tumour is found on cystoscopy, the GPwSI will place the patient directly on to the consultant’s theatre list in the acute trust; this will be the first time the consultant sees the patient.

After surgery, the patient will be returned to the care of the GPwSI at the centre for any necessary follow up.

The current waiting time for cystoscopy is less than 2 weeks and we plan to reduce this to less than 1 week very soon.

Most patients do not need to visit the acute trust. Diagnosis, treatment and management is all carried out within the diagnostic treatment centre.

Three GPwSIs and four nurses trained in triage make up our PCT’s urology team. We have recently provided training in cystoscopy for a GP in a neighbouring PCT, who will be using our premises to deliver services to his own patients.

The patient information and consent policy we use are consistent with the acute trust guidelines.

The success of the service

The service has proved successful in several areas. For example, in 2001 the waiting time for a rheumatology appointment at our local trust was 20 weeks. With the introduction of two GPwSIs, each working one session per week at our primary care centre, the waiting time has been reduced to 4 weeks in primary care and 3 weeks in the local trust.

In 2001, the waiting time for an ENT appointment at the local trust was also 20 weeks. The introduction of two GPwSIs each of whom works one session per week at our primary care centre has reduced the waiting time to 5 weeks in primary care and 12 weeks in the local trust.

Reductions of this sort have been achieved in most services delivered in primary care where we have introduced GPs and nurses with extended skills. Patients are now receiving appropriate care, close to home, more quickly.

Patient satisfaction surveys of all the services delivered from the diagnostic treatment centre were carried out in November 2001 and November 2002. The results showed that the needs of the patients in Bradford South & West PCT – to be seen locally and quickly by an appropriate specialist – were being met. Surveys carried out in the individual specialties found that patients were very satisfied with the centre, the consultation with the GPwSI, staff and waiting times.

The Bradford Primary Care Accreditation Panel, hosted by Bradford South & West PCT, ensures that GPs providing secondary care services in a primary care setting are accredited to standards that are consistently high across the district.

The scheme was awarded Beacon status in October 2000.

The future of the service

Our clinical governance directorate is working with local secondary care providers to agree more defined training programmes, and discussions are underway with educational bodies concerned with medical training about a national programme.

We are aiming for a uniform approach to audit undertaken by GPwSIs, and hope also to include data from local trusts and groups.

NHS Beacon Awards
Beacon status is awarded to practices, trusts and other healthcare organisations within the NHS that have demonstrated good practice. The NHS Beacon programme aims to spread best practice across the health service. For further information visit the website: www.nhs.uk/beacons

NICE has published a new guideline (Faltering growth: recognition and management of faltering growth in children) and updated two guidelines (Urinary tract infection in under 16s: diagnosis and management and Immunisations: reducing differences in uptake in under 19s).

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